Health inspection·February 27, 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 observation, interview, and record review, the facility failed to ensure immediate measures were put into place to provide protections to one of three sampled resident (Resident 3) when a License Vocational Nurse (LVN) and a Program Counselor (PC) were not suspended immediately after an alleged abuse to Resident 3 was reported on February 14, 2024. Residents Affected - Some This failure had the potential for further abuse, neglect, exploitation, or mistreatment in a vulnerable population of 68 residents as the alleged perpetrators, LVN and PC, continued to have access to the alleged victim, Resident 3, and to other residents while the investigation was still in process. Findings: During a review of Resident 3 ' s admission Record (clinical record with demographic information), it indicated Resident 3 was admitted to the facility on [DATE], with diagnoses of schizoaffective disorder (a chronic mental health condition that affects your mood and perception of reality) bipolar type (with episodes of manic that can shift to major depressive episodes), delusional disorder (a serious mental illness where you can't tell the difference between what's real and what's not) and generalized anxiety disorder (a mental disorder often worried or anxious about many things and hard to control). A review of Resident 3 ' s history and physical examination, dated September 28, 2023, indicated Resident 3 has the capacity to understand and make decisions. A review of State of California (SOC) Form 341 [Report of Suspected Dependent Adult/Elder Abuse ], dated February 14, 2024, indicated . A. VICTIM . [Resident 3 name] . B. SUSPECTED ABUSER [LVN and PC name] . F. REPORTED TYPES OF ABUSE . b. Sexual [marked] . A review of Resident 3 ' s Interdisciplinary Team (IDT- group of healthcare providers who work together or toward the same goal) Notes, dated February 16, 2024, indicated . On 2/14/2024 (February 14, 2024) approx. [approximately] 8pm resident [Resident 3] approached the CN [charge nurse] and stated to her I have something to tell you. Then the resident proceeded to say A couple of weeks ago when my roommate was in the hospital, the CN came into my room and asked if I wanted to know a secret, but you can't tell no one. I think your cute and kissed her forehead then left the room . Resident mentioned that she felt uncomfortable, but it never happened again. Then the resident mentioned that months ago the PC came into my room and started to kiss me and sucked my pussy [slang word for vagina] .IDT recommendation: . Monitor for clinical changes: Pain and emotional wellbeing distress. Safeguard resident from alleged/ suspected abuse, Psychology/Psychiatry consults as needed. Page 1 of 3 555514 555514 02/27/2024 Heritage Park Nursing Center 275 Garnet Way Upland, CA 91786

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview, on February 16, 2024, at 2:50 PM, with the Director of Staff Development (DSD), the DSD stated on February 14, 2024, around 8:30 PM, the nurse in charge called her over the phone and told her about the abuse allegation reported by Resident 3 against two staff members. The DSD stated she attempted to call the Administrator, but he did not answer so she went ahead and notified LVN to continue to come to work and to have another staff to accompany him with anything he needs to do with Resident 3. The DSD further stated she called and notified PC the next morning to continue come to work and to keep his distance toward Resident 3. During an interview, on February 16, 2024, at 3:00 PM, with PC, PC stated on February 15, 2024, around 8:00 AM, the DSD called him over the phone and told him about the abuse allegation reported by Resident 3. PC further stated the DSD asked him to continue to come to work and to keep his distance toward Resident 3. During a concurrent interview and record review, on February 16, 2024, at 3:15 PM, with the DSD, the DSD reviewed PC ' s timesheet which indicated, .[named of the PC] date 2/15 in 8:33 AM . out 12:53 PM . in 1:17 PM . out 5:05 PM . date 2/16 in 8:11 AM . out 12:49 PM . in 1:20 PM . The DSD stated she was not aware that PC needed to be removed immediately during investigation. (PC continued to have access to the alleged victim, Resident 3, and to the other 67 residents for 2 consecutive days during 8:00 AM – 5:00 PM shifts.) During a phone interview, on February 21, 2024, at 3:45 PM, with LVN, LVN stated on February 14, 2024, around 11:25 PM, when LVN came to his shift, he called the DSD, and the DSD informed him about the abuse allegation reported by Resident 3. LVN further stated the DSD asked him to continue working as scheduled and to have another staff to accompany him with anything he needs to do with Resident 3 and the LVN confirmed worked both days, February 14, 2024, and February 15, 2024, on night shifts. A review of LVN timesheet which indicated, .[named of the LVN] 2/01/2024 – 2/29/2024 selected range of date . date 2/14 in 11:16 PM . out 7:18 AM [February 15, 2024] . date 2/15 in 11:33 PM . out 7:13AM [February 16, 2024] . During a concurrent interview and record review, on February 16, 2024, at 3:50 PM, with the DSD, the facility nursing staff assignment sign-in sheet, which indicated .Wednesday 2/14/2024 .NOC shift 11:00 PM-7:00PM [name of LVN] . assignment 101-116B . [LVN signatured] . Wednesday 2/15/2024, indicated LVN was on duty .NOC shift 11:00 PM-7:00PM [name of LVN] . assignment 101-116B . [LVN signatured] . The DSD stated she was not aware that LVN needed to be removed immediately during investigation. (LVN, continued to have access to the alleged victim, Resident 3, and to the other 67 residents for 2 consecutives nights during 11:00 PM – 7:00AM shifts) During an interview, on February 16, 2024, at 4:00 PM, with the Social Service Department (SSD), the SSD acknowledged the facility policy was to suspend the respective employee immediately while the investigation was in process to protect the resident(s). The SSD stated she assumed the investigation is concluded when she saw the PC continue coming to work on February 15 , 2024 and today [February 16, 2024]. The SSD further stated she should have followed up with DON or/and Administrator to make sure the status of the investigation instead of assuming the conclusion of the investigation. During an interview, on February 16, 2024, at 4:10 PM, with the Director of Nursing (DON) the DON acknowledged that the investigation was not yet concluded, and the facility policy was to suspend the respective employee immediately while the investigation was in process to protect the resident (s). The DON stated it slipped her mind. The DON further stated she should have immediately removed the 555514 Page 2 of 3 555514 02/27/2024 Heritage Park Nursing Center 275 Garnet Way Upland, CA 91786

F 0610 two staff members to protect Resident 3 and the other 67 residents. Level of Harm - Minimal harm or potential for actual harm During a concurrent interview and record review, on February 16, 2024, at 4:20 PM, with the DON, the facility ' s policy, and procedure (P&P) titled, Abuse Investigation/Prevent/Report Alleged Violation revised March 2018, was reviewed. The P&P indicated, POLICY STATEMENT The facility thoroughly investigates allegations of abuse, neglect, exploitation, or mistreatment; ensures residents' safety from further potential abuse while the investigation is in progress; and maintains evidence and reports results of investigations to the Administrator and other officials in accordance with State law, including the State Survey Agency. SAFETY PROCEDURE(S) 1. To ensure resident safety, employees accused of participating in the alleged abuse will be suspended until the findings of the investigation have been reviewed by the administrator. The DON stated the facility did not follow the policy. Residents Affected - Some 555514 Page 3 of 3