Health inspection·May 14, 2024

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) was free from sexual abuse when Resident 1 and Resident 2 were left alone in the activity room and Resident 2 touched Resident 1's inner thigh. This failure had the potential to endure emotional and psychological harm for Resident 1. Findings: Review of Resident 1's admission record indicated she was admitted to the facility on [DATE] with diagnoses including vascular dementia (brain damage caused by multiple strokes [occurs when blood supply going to the brain is blocked or reduced] and cognitive communication deficit (trouble participating in conversations). Review of Resident 1's Minimum Data Set (MDS, an assessment tool) dated 3/21/24 indicated her Brief Interview for Mental Status (BIMS, a tool used to have a snapshot of a resident cognitive function) was 00 (score of 0 to 7 indicates severe cognitive impairment). Review of Resident 2's admission record indicated he was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease (a progressive disease that affects memory and other mental functions) and dementia (loss of cognitive function like thinking, remembering, and reasoning). Review of Resident 2's MDS dated [DATE] indicated his BIMS score was 5. Review of Resident 1's Situation Background Assessment Recommendation (SBAR, a verbal or written communication tool used by healthcare professional) date 4/19/24, indicated at approximately 7:14 p.m., Resident 3 went to the activity room and witnessed Resident 2 putting his hands inside Resident 1's pants. Resident 3 called Registered Nurse A (RN A) and RN A went to the activity room and saw Resident 2's hands inside Resident 1's pants touching her inner thigh. During an interview with RN A on 4/25/24 at 2:30 p.m., RN A stated when Resident 3 called her attention she immediately went to activity room and saw Resident 2's hands inside Resident 1's pants touching her inner thigh. RN A further stated Resident 1 was wearing above knee-length loose pants at that time. During an interview with Licensed Vocational Nurse B (LVN B) on 4/29/24 at 1 p.m., she stated the activity room had supervision during daytime and after 6 p.m., there will be no staff supervising the activity room. (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: 555838 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 555838 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Camden Postacute Care, Inc 1331 Camden Avenue Campbell, CA 95008 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)