Health inspection·August 8, 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, facility document review, and facility P&P review, the facility failed to implement the P&P for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act when the facility did not report an allegation of abuse to the CDPH, L&C Program for one of seven sampled residents (Resident 5). This failure had the potential for Resident 5 to be vulnerable to further abuse and emotional distress. Findings: Review of the facility's P&P titled Policy on Abuse Prevention and Mandated Reporting (undated) showed all alleged violations involving abuse, neglect, exploitation, or mistreatment including injuries of an unknown source and misappropriation of property will be reported by the facility Administrator or his/her designee to the State licensing/certification agency responsible for surveying/licensing the facility. Alleged abuse, neglect, exploitation, or mistreatment will be reported within two hours if the alleged events have resulted in serious bodily injury. If events that cause the allegation do not involve abuse or not resulted in serious bodily injury, the report must be made within 24 hours. Medical record review for Resident 5 was initiated on 8/7/24. Resident 5 was admitted to the facility on [DATE]. Review of Resident 5's MDS dated [DATE], showed Resident 5 had a BIMS score of 15 which indicated Resident 5 was cognitively intact. On 8/6/24, CDPH, L&C Program received an investigation report from the facility which showed Resident 5 alleging she was abused in the facility because her meals were not delivered, the staff were not answering her call lights, and she was being retaliated against on 8/1/24. The facility failed to report the abuse allegation timely as per the facility's P&P. Review of the facility's fax Transmission Log showed the facility sent the SOC 341 and reported the abuse allegation to CDPH, L&C Program on 8/1/24 at 1351 hours. However, the fax number listed on the Transmission Log was not the fax number for CDPH, L&C Program. On 8/7/24 at 1450 hours, an interview and concurrent facility document review was conducted with the Administrator. The Administrator verified the fax Transmission Log showed the SOC 341 was sent to CDPH, L&C Program on 8/1/24. However, the Administrator verified the fax number listed on 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: 555445 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 555445 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Anaheim Crest Nursing Center 3067 W Orange Avenue Anaheim, CA 92804 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)