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 Page 1 of 2 555514 555514 05/23/2025 Heritage Park Nursing Center 275 Garnet Way Upland, CA 91786

F 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few incident to ensure whether necessary interventions were taken to address any harm, prevent recurrence, and to protect Resident 3 ' s health and safety. During an interview on April 16, 2025, at 12:15 PM, with the Program Director (PD), the PD stated, I was just caught up in what the police officer said, so I didn ' t think I needed to do more at that time. The PD acknowledged she should have been more thorough in investigating and observing Resident 3 to ensure necessary interventions were taken for her safety and well-being, but she did not. During an interview on April 16, 2025, at 12:45 PM, with the Director of Nurses (DON), the DON stated the facility should have initiated the investigation immediately on April 10, 2025. During an interview on April 16, 2025, at 1:00 PM, with the Administrator (Admin), the Admin stated the investigation should have been initiated on April 10, 2024, according to their facility policy. During a concurrent interview and record review, on April 16, 2025, at 2:00 PM, with the Admin, the facility ' s P&P titled, Abuse, Neglect, Exploitation or Misappropriation -Reporting and Investigating revised September 2022, was reviewed. The P&P indicated, Policy Statement. 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 . Policy Interpretation and Implementation Investigating Allegations. 1. All allegations are thoroughly investigated. The administrator initiates investigations. The Admin stated the facility did not follow the policy. 555514 Page 2 of 2