Health inspection·April 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 and record review, the facility failed to report an alleged sexual abuse for one of three sampled residents (Resident 2) by another resident to the local, state and agencies. This failure had the potential to place a clinically compromised resident (Resident 2)'s health, safety and well-being at risk. Findings: During review of Residents 2's admission Record (general demographics), the document indicated Resident 2 was admitted to the facility on [DATE], with diagnoses that included schizoaffective disorder (a condition of mental illness), major depressive disorder (a condition of feeling of sadness) and hypertension (a condition with a high blood pressure). During an interview on April 8, 2024, at 2:30 PM, with the Director of Nursing (DON), the DON stated, We do investigations and report to the appropriate agencies including CDPH (California Department of Public Health). When asked who does the reporting, the DON stated, The Administrator usually does it, but all licensed staff and department heads are responsible for reporting. takes care of it. During an interview on April 8, 2024, at 2:35 PM, with the Administrator, the Administrator was asked if a report of the alleged sexual abused for Resident 2 was made to the appropriate agencies. The Administrator stated, We filled out a report to the agencies, we cannot find it, it is missing. During a second interview on April 8, 2024, at 3:40 PM, with the Administrator, when asked for a 5-day investigation summary for the alleged sexual abuse incident, the Administrator stated, There is no 5-day investigation summary. During a review with the Administrator on April 8, 2024, at 3:40 PM, the facility's policy titled, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating dated September 2022, was reviewed. The policy indicated, All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported . Reporting Allegations to the Administrator and Authorities . 4. Verbal/written notices to agencies are submitted via special carrier, fax, e-mail, or by telephone . Investigating Allegations 1. All allegations are thoroughly investigated. The Administrator initiates investigations . Follow-Up Report. 1. Within five (5) business days of the incident, the administrator will provide a follow-up investigation report. (2) Page 1 of 2 555514 555514 04/08/2024 Heritage Park Nursing Center 275 Garnet Way Upland, CA 91786

F 0609 The follow-up investigation report will provide sufficient information to describe the results of the investigation, and indicate any corrective actions taken if the allegation was verified . Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 555514 Page 2 of 2