Health inspection·May 23, 2025

F 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow their policy and procedure for investigating an allegation of suspected physical abuse for one of three sampled resident (Resident 3), when the facility did initiate an investigation for the incident within specified timeframes after Resident 3 reported an alleged abuse by another resident to the Administrator on April 2, 2025. Residents Affected - Few This failure has the potential to jeopardize Resident ' s 3 health, safety, and well-being at risk and the other vulnerable population of 69 residents. Findings: A review of State of California Form 341 [Suspected Dependent Adult/Elder Abuse form], dated April 10, 2025, indicated . While Ombudsman [a person who helps solve complaints and problems between people and organizations, making sure things are fair] was visiting the facility [Resident 3] reported to the Ombudsman that [Resident 2] forced sex on her [Resident 3] last week on a Wednesday night (4/2/25 [April 2, 2025]) between 10:30pm-11:00pm while she was sleeping. During a review of Residents 3 ' s admission Record (general demographics), it indicated Resident 3 was admitted to the facility on [DATE], with diagnoses to include schizoaffective disorder (serious mental health condition) and major depression (mood disorder that causes a persistent feeling of sadness and loss of interest). During a review of Resident 3 ' s Minimum Data Set assessment, dated March 31, 2025, it indicated Resident 3 had a BIMS score of 14. During a review of Resident 3 ' s eINTERCT Change in Condition Evaluation dated April 10, 2025, it indicated . Resident reported to ombudsman that another resident had assaulted her sexually . During a review of Resident 3 ' s Report of alleged Incident dated April 11, 2025, it indicated .On April 10, 2025, at approximately 4:45 PM, while the Ombudsman was present on the unit, a resident reported that another resident, identified as . [Resident 2], had forced sexual contact on her [Resident 3]. Upon further inquiry, the resident stated that on the night of Wednesday, April 2, between approximately 10:30 PM and 11:00 PM, resident [Resident 2] entered her [Resident 3] room and had sex with her while she was sleeping . notified of the allegation and promptly informed the facility Administrator, the Behavioral Health Nurse Director/ADON, the resident's psychiatrist, . During a review of Resident 3 ' s clinical record from April 10, 2025, to April 16, 2025, there was no documented evidence to indicate an investigation had been initiated following the reported (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: 555514 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 05/23/2025 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)