Health inspection·March 27, 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 interviews and record review, the facility failed to report an incident of alleged abuse involving one of one sampled resident (Resident 1) to the Department in accordance with State law within five working days of the incident. Resident 1 made sexual allegations against one CNA 1 who worked at the facility. This deficient practice had the potential for the underreporting of abuse incidents and a delay in an investigation of abuse allegations, placing the affected Resident 1 and/or other residents at risk for potential further abuse. Findings: During a concurrent interview and record review on 3/27/2024 at 10:08 a.m. with Director of Nursing Services (DON), Resident 1's initial psychiatric evaluation, dated 2/23/2024, was reviewed. The initial psychiatric evaluation indicated that Resident 1 was admitted on [DATE], to the Skilled Nursing Facility section. with a diagnosis including mild cognitive impairment (a mental condition related to a disconnection with reality) amongst other past medical history. During a review of Resident 1's Initial Psychiatric Evaluation (a commonly use assessment used to diagnose mental disorders), dated 2/23/2024, the initial psychiatric evaluation indicated Resident 1's diagnosis of unspecified psychosis (a mental condition related to a disconnection with reality) rule out major neurocognitive disorder (a decreased in mental function and loss of ability to do daily task) with psychosis. During an interview on 3/27/2024 at 10:15 a.m. with Social Worker (SW), SW stated that the staff initially reported the incident on 2/16/2024, and SW went to meet and interview Resident 1. SW stated that Resident 1 changed the story three days (2/19/2024) later, SW stated that Resident 1 reported that CNA 1 did something sexual to his wife. During an interview on 3/27/2024, at 10:34 a.m., with CNA 1, CNA 1 stated that he (CNA 1) had been working at the facility for two years. CNA 1 stated that he (CNA 1) got the assignment, he (CNA 1) opened the door to Resident 1's room and saw her (Resident 1's wife) coming out of the bathroom around 7 a.m. on 2/16/24. CNA 1 stated that he (CNA 1) offered to pick up her (Resident 1's wife) clothes and she (Resident 1's wife) went back to the bed. Resident 1 approached CNA 1 and told CNA 1 to get out of the room. CNA 1 reported what happened to the charge nurse (CN). CN informed CNA 1 to exchange resident with another CNA. CNA 1 stated that he (CNA 1) never went back to the room of Resident 1. Since then, CNA 1 stated that he (CNA 1) had never been to the room, CNA 1 said that he (CNA 1) had been assigned to a different area and different floor and continued to work for the remainder of (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 4 Event ID: 555846 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 555846 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/27/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Joyce Eisenberg Keefer Medical Center D/P Snf 7150 Tampa Avenue Reseda, CA 91335 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)