Health inspection·February 27, 2024

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 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555514 If continuation sheet Page 2 of 3 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 555514 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/27/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Heritage Park Nursing Center 275 Garnet Way Upland, CA 91786 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)

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 FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555514 If continuation sheet Page 3 of 3