Health inspection·May 9, 2025

F 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to perform a thorough investigation and report for six of six residents (Residents 1, 2, 3, 4, 5, and 6). Residents Affected - Few This failure had the potential to compromise the facility's ability to determine the circumstances surrounding the incidents and could have compromised the residents' safety. Findings: During a review of the 5-day investigation summary of an alleged abuse by a certified nursing assistant (CNA) to Residents 1 and 2, the summary did not indicate the outcome for the facility's investigation of whether the facility was able to determine if they thought the alleged abuse by the CNA did occur, or not. During an interview on 4/25/25 at 3:49 p.m., with the administrator (ADM), the ADM stated that he tried to send the 5-day follow-up investigations for Resident 1 and 2 but failed. He was not able to verify if the allegations were substantiated or not. The ADM also stated the facility's 5-day follow-up investigation for the incidents had not followed their abuse policy and procedure (P&P). During a review of the 5-day investigation summary of an alleged physical altercation between Residents 3 and 4, the summary did not indicate the outcome for the facility's investigation of whether the facility was able to determine if they thought the physical altercation did occur, or not. During a review of the 5-day investigation summary of an alleged physical altercation between Residents 5 and 6, the summary did not indicate the outcome for the facility's investigation of whether the facility was able to determine if they thought the physical altercation did occur, or not. During a concurrent interview and record review on 5/9/25 at 10:47 a.m., the ADM, he reviewed the facility's 5-day follow-up for the incidents and the facility's Abuse and Neglect Prohibition policy and procedure. The ADM also stated the facility's 5-day follow-up investigation for the incidents had not followed their abuse P&P. A review of the facility's policy and procedure (P&P) dated 6/2022, titled Abuse, Neglect, Prohibition, the P&P indicated, All reports of resident abuse .are reported to local ombudsman or local law enforcement, state, and federal agencies .and thoroughly investigated by facility management. Findings of all investigations are documented on the facility's investigation form, log and reported . The administrator or designee will report findings of all completed investigations to the Licensing and Certification Program District Office via fax and other officials in accordance with law within five (5) working days of the incident and take all necessary, corrective actions depending on 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: 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 05/09/2025 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)