Health inspection·July 16, 2024

F 0609 Level of Harm - Potential for minimal harm Residents Affected - Some 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, medical record review, and facility P&P review, the facility failed to implement their P&P for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act when an allegation of abuse involving CNA 1 and one of three sampled residents (Resident 1) was not reported timely to the CDPH, L&C Program. This failure posed the risk of potential abuse to go unreported and uninvestigated. Findings: Review of the facility's P&P titled Abuse Recognition/Reporting Elder/Dependent revised 2/2024 showed any instance of alleged or suspected abuse involving a resident will be reported in accordance with Welfare and Institutional Codes of the State of California, Federal Law, California Health and Safety Codes, and the Elder Abuse and Dependent Adult Civil Protection Act. The facility is required to report all incidents of alleged abuse or suspected abuse to the Department of Health Services within 24 hours. Review of the SOC 341 Report of Suspected Dependent Adult/Elder Abuse dated 6/28/24, showed Resident 1's family members accused CNA 1 of hitting Resident 1. Medical record review for Resident 1 was initiated on 7/15/24. Resident 1 was admitted to the facility on [DATE]. Review of Resident 1's H&P examination dated 3/14/24, showed Resident 1 was cognitively intact. Review of Resident 1's Nursing Notes dated 6/22/24, showed Resident 1 sustained a scratch on the left temple area. On 7/15/24 at 0915 hours, an interview was conducted with CNA 1. CNA 1 stated he had noted an abrasion above Resident 1's left eye and reported it to the LVN. CNA 1 stated he was unsure how the injury had occurred. CNA 1 stated Resident 1's family members approached him on 6/23/24, and accused him of causing Resident 1's injury on the left temple area. CNA 1 further stated the charge nurse was in the nursing station with him and overheard the situation. CNA 1 stated the abuse should be reported right away to the charge nurse. On 7/16/24 at 1015 hours, an interview was conducted with RT 1. RT 1 stated he heard Resident 1's family members accusing CNA 1 of causing Resident 1's injury on the left temple area. (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: 555883 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 555883 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/16/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE West Anaheim Medical Center D/P Snf 3033 W Orange Ave Anaheim, CA 92804 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)