Health inspection·March 13, 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, facility document review, and facility P&P review, the facility failed to implement the P&P for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act. Resident's 1 allegation of physical abuse was not reported to the local enforcement agency as per the facility's P&P. This failure had the potential for the abuse allegation going unreported and uninvestigated. Findings: Review of the facility's P&P titled Elder Abuse;Identification Investigation & Reporting dated January 2024 showed the Administrator in conjunction with the Director of Nursing notifies the following of a suspected abuse incident within two (2) hours if the alleged violation involves abuse or serious bodily injury; and 24 hours if the alleged violation does not involve abuse and does not result in serious bodily injury: a. state licensing/certification agency; b. local ombudsman; c. resident's legal representative of record (via telephone); d. resident's attending physician (via telephone); e. law enforcement; and f. Adult Protective Services as deemed appropriate. Review of the facility's SOC 341 form dated 3/9/24, showed a physical abuse allegation made by Resident 1 against the CNA staff members. Medical record review for Resident 1 was initiated on 3/12/24. Resident 1 was admitted to the facility on [DATE]. Further review of the facility's SOC 341 form showed the facility reported Resident 1's physical abuse allegation against the CNA staff members to the local ombudsman and CDPH, L&C Program. However, further review of the medical record and SOC form showed no documented evidence the (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: 555515 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 555515 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/13/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Vista at Morningside 2525 Brea Blvd. Fullerton, CA 92835 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)