Health inspection·September 20, 2024

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the California Department of Public Health during an abbreviated standard survey. Facility Reported Incidents (FRI): CA00912601 and CA00913805 The inspection was limited to specific Facility Reported Incidents investigated and does not represent the findings of a full inspection of the facility. Two deficiencies were issued for FRI CA00912601 (Refer to F600 and F609). No deficiencies were issued for CA00913805.

F600 SS=D Free from Abuse and Neglect CFR(s): 483.12(a)(1)

F600 08/29/2024 §483.12 Freedom from Abuse, Neglect, and Exploitation The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. §483.12(a) The facility must§483.12(a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion; This REQUIREMENT is not met as evidenced by: LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE 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. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5MEJ11 Facility ID: CA950000062 If continuation sheet 1 of 11 PRINTED: 05/13/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055376 (X3) DATE SURVEY COMPLETED 08/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HUNTINGTON DRIVE HEALTH AND REHABILITATION CENTER 400 W Huntington Dr Arcadia, CA 91007 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Based on observation, interview and record review, the facility failed to protect one (1) of three (3) sampled residents (Resident 1 from verbal abuse (a type of mental abuse [the use of verbal or nonverbal conduct which causes or has the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation, or degradation] with (the use of oral, written, or gestured communication, or sounds, to residents within hearing distance, regardless of age, ability to comprehend, or disability) based on the facility's policy and procedure. This deficient practice had resulted to Resident 1 experiencing verbal abuse from Resident 2 which could affect Resident 1's emotional and psychosocial wellbeing. Findings: 1. During a review of Resident 1's Admission Record, the Admission Record indicated Resident 1 was admitted to the facility on 4/14/2023 with diagnoses of diabetes mellitus (DM, a metabolic disease, involving inappropriately elevated blood glucose levels), dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), and hypertension (high blood pressure). During a review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 7/18/2024, the MDS indicated Resident 1 had severely impaired cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. The MDS also indicated Resident 1 needed substantial/maximal assistance (helper does more than half the effort. Helper lifts or holds trunk or limbs but FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5MEJ11 Facility ID: CA950000062 If continuation sheet 2 of 11 PRINTED: 05/13/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055376 (X3) DATE SURVEY COMPLETED 08/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HUNTINGTON DRIVE HEALTH AND REHABILITATION CENTER 400 W Huntington Dr Arcadia, CA 91007 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE provides more than half the effort) in shower/ bathe self, lower body dressing, and putting on/taking off footwear, lying and sitting on the side of the bed, sit to stand position, toilet transfer and tub/shower transfer. During a review of Resident 1's Situation, Background, Assessment, Recommendation (SBAR, a verbal or written communication tool that helps provide essential, concise information, usually during crucial situation), dated on 7/31/2024, indicated Resident 1's roommate (Resident 2) was cursing in the room while resident (Resident 1) was present. During a review of a facility form titled, "PostEvent Review," dated 8/2/2024, the form indicated a resident-to-resident altercation on 7/31/2024 at 8 AM. It indicated that Resident 1's roommate (Resident 2) was noted to have verbal aggression while resident (Resident 1) was present in the room. It indicated that the Director of Nursing (DON) was notified by the staff that Resident 1's roommate (Resident 2) was heard cursing while Resident 1 was present in the room. 2. During a review of Resident 2's Admission Record, the Admission Record indicated the resident was initially admitted to the facility on 9/12/2023 with diagnoses of Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks), dementia, and hypertension. During a review of Resident 2's MDS, dated 6/19/2024, the MDS indicated Resident 2 had severely impaired cognitive skills for daily decision making. The MDS also indicated Resident 2 required partial moderate assistance (helper does less than half the effort. Helper lifts, holds, or supports trunk or FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5MEJ11 Facility ID: CA950000062 If continuation sheet 3 of 11 PRINTED: 05/13/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055376 (X3) DATE SURVEY COMPLETED 08/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HUNTINGTON DRIVE HEALTH AND REHABILITATION CENTER 400 W Huntington Dr Arcadia, CA 91007 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE limbs, but provides less than half of the effort) in shower/ bathe self, upper and lower body dressing, putting on/ taking off footwear, personal hygiene, and tub/shower transfer. During a review of Resident 2's SBAR, dated 7/31/2024, indicated Resident 2 had verbal aggression with alleged abuse. It indicated that Resident 2 was heard cursing in Spanish while wheeling herself to the bathroom while roommate (Resident 1) was present in the room. During a review of a facility form titled, "PostEvent Review," dated 8/2/2024, the form indicated a resident-to-resident altercation on 7/31/2024 at 8:10 AM. It indicated that the Director of Nursing (DON) was notified by the staff that Resident 2 was heard cursing while wheeling herself to the restroom. It further indicated that Resident 2 was attempting to wheel herself to the bathroom however resident was unable to fully open the bathroom door due to roommate's (Resident 1) bedside table was in the way. It indicated Resident 2 started cursing with roommate present in the room, possibly out of frustration and that resident was on monitoring for verbal aggression at this time. During an interview with the Medical Records Assistant (MRA) on 8/6/2024 at 8:53 AM, MRA stated when she went to the nurse's station on 7/31/2024, she heard a resident cursing in Spanish. MRA stated she went to Residents 1 and 2's room and witnessed Resident 2 come out of the restroom and slammed the door. During an interview with MRA on 8/6/2024 at 9:04 AM, MRA stated, it was her first time to witness a verbal abuse when Resident 2 cursed Resident 1. During an interview with Certified Nursing FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5MEJ11 Facility ID: CA950000062 If continuation sheet 4 of 11 PRINTED: 05/13/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055376 (X3) DATE SURVEY COMPLETED 08/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HUNTINGTON DRIVE HEALTH AND REHABILITATION CENTER 400 W Huntington Dr Arcadia, CA 91007 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Assistant 1 (CNA 1) on 8/6/2024 at 12:29 PM, CNA 1 stated, a resident cursing at other people is verbal abuse. CNA 1 stated, "It is very offensive if the other resident hears it." During an interview with the Laundry Personnel (LDP) on 8/6/2024 at 1:20 PM, LDP stated "on 7/31/2024, she witnessed Resident 1 being yelled and cursed in Spanish by Resident 2 by saying, "Move, you son of a b_ _ _ ch." LDP stated she heard the same cursing words that MRA heard inside Resident 1's room. LDP stated this was considered verbal abuse. LDP stated she always hear Resident 2 insult and say bad words to Resident 1 every day. LDP stated she did not report the abuse incidents because she was scared to get in trouble. During an interview with the Maintenance Supervisor (MTS) on 8/6/2024 at 1:38 PM, MTS stated it is considered "verbal abuse if a resident curses at another resident. MTS stated, "We have to report it (verbal abuse). I don't think it is okay to be mean to someone else. I will really feel bad if I or my loved ones would hear it." During an interview with the LDP on 8/6/2024, at 1:28 PM, LDP stated according to the inservice she attended, abuse should be reported. LDP stated she was not aware of the timeline for abuse reporting. During a concurrent review of Resident 2's SBAR, dated 7/31/2024, and interview with the Director of Nursing (DON) on 8/6/2024, at 1:48 PM, the DON stated the SBAR indicated Resident 2 was verbally aggressive and was cursing her roommate. The DON stated, "Hearing cursing words is considered verbal abuse because it is hurtful towards the other person." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5MEJ11 Facility ID: CA950000062 If continuation sheet 5 of 11 PRINTED: 05/13/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055376 (X3) DATE SURVEY COMPLETED 08/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HUNTINGTON DRIVE HEALTH AND REHABILITATION CENTER 400 W Huntington Dr Arcadia, CA 91007 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE During an interview with Director of Nursing (DON) on 8/6/2024, at 2:09 PM, the DON stated, it was important to report abuse to keep the resident safe and prevent another incident." During a review of the facility's Policy and Procedure (P&P) titled, "Abuse, Neglect, Exploitation and Misappropriation Prevention Program," revised 4/2021, the P&P indicated the resident has the right to be free from abuse ...Protect residents from abuse, neglect, exploitation, or misappropriation of property by anyone including, but not necessarily limited to other residents. Identify and investigate all possible incidents of abuse, neglect, mistreatment ... Investigate and report any allegations within timeframes required by federal requirements.

F609 SS=D Reporting of Alleged Violations CFR(s): 483.12(b)(5)(i)(A)(B)(c)(1)(4)

F609 08/29/2024 §483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: §483.12(c)(1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5MEJ11 Facility ID: CA950000062 If continuation sheet 6 of 11 PRINTED: 05/13/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055376 (X3) DATE SURVEY COMPLETED 08/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HUNTINGTON DRIVE HEALTH AND REHABILITATION CENTER 400 W Huntington Dr Arcadia, CA 91007 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE §483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. This REQUIREMENT is not met as evidenced by: Based on interview and record review the facility failed to report an allegation of verbal abuse (the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish) for one (1) of three sampled residents (Residents 1) within 2-hour timeframe to the State Survey Agency (SA, where state law provides for jurisdiction in long-term care facilities), the state ombudsman (advocates for residents of nursing homes, board and care homes and assisted living facilities), and local law enforcement. This deficient practice had the potential to compromise or impede the protection of Resident 1, which could affect the resident's emotional and mental wellbeing. Findings: 1. During a review of Resident 1's Admission Record, the Admission Record indicated Resident 1 was admitted to the facility on 4/14/2023 with diagnoses of diabetes mellitus (DM, a metabolic disease, involving inappropriately elevated blood glucose levels), dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), and hypertension (high blood pressure). FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5MEJ11 Facility ID: CA950000062 If continuation sheet 7 of 11 PRINTED: 05/13/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055376 (X3) DATE SURVEY COMPLETED 08/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HUNTINGTON DRIVE HEALTH AND REHABILITATION CENTER 400 W Huntington Dr Arcadia, CA 91007 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE During a review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 7/18/2024, the MDS indicated Resident 1 had severely impaired cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. The MDS also indicated Resident 1 needed substantial/maximal assistance (helper does more than half the effort. Helper lifts or holds trunk or limbs but provides more than half the effort) in shower/ bathe self, lower body dressing, and putting on/taking off footwear, lying and sitting on the side of the bed, sit to stand position, toilet transfer and tub/shower transfer. During a review of a facility form titled, "PostEvent Review," dated 8/2/2024, the form indicated a resident-to-resident altercation on 7/31/2024 at 8 AM. It indicated that Resident 1's roommate (Resident 2) was noted to have verbal aggression while resident (Resident 1) was present in the room. It indicated that the Director of Nursing (DON) was notified by the staff that Resident 1's roommate (Resident 2) was heard cursing while Resident 1 was present in the room. 2. During a review of Resident 2's Admission Record, the Admission Record indicated the resident was initially admitted to the facility on 9/12/2023 with diagnoses of Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks), dementia, and hypertension. During a review of Resident 2's MDS, dated 6/19/2024, the MDS indicated Resident 2 had severely impaired cognitive skills for daily decision making. The MDS also indicated Resident 2 required partial moderate FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5MEJ11 Facility ID: CA950000062 If continuation sheet 8 of 11 PRINTED: 05/13/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055376 (X3) DATE SURVEY COMPLETED 08/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HUNTINGTON DRIVE HEALTH AND REHABILITATION CENTER 400 W Huntington Dr Arcadia, CA 91007 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE assistance (helper does less than half the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half of the effort) in shower/ bathe self, upper and lower body dressing, putting on/ taking off footwear, personal hygiene, and tub/shower transfer. During a review of a facility form titled, "PostEvent Review," dated 8/2/2024, the form indicated a resident-to-resident altercation on 7/31/2024 at 8:10 AM. It indicated that the Director of Nursing (DON) was notified by the staff that Resident 2 was heard cursing while wheeling herself to the restroom. It further indicated that Resident 2 was attempting to wheel herself to the bathroom however resident was unable to fully open the bathroom door due to roommate's (Resident 1) bedside table was in the way. It indicated Resident 2 started cursing with roommate present in the room, possibly out of frustration and that resident was on monitoring for verbal aggression at this time. During an interview with the Medical Records Assistant (MRA) on 8/6/2024 at 8:53 AM, MRA stated when she went to the nurse's station on 7/31/2024, she heard a resident cursing in Spanish. MRA stated she went to Residents 1 and 2's room and witnessed Resident 2 come out of the restroom and slammed the door. During an interview with MRA on 8/6/2024 at 9:04 AM, MRA stated, it was her first time to witness a verbal abuse when Resident 2 cursed Resident 1. During an interview with Certified Nursing Assistant 1 (CNA 1) on 8/6/2024 at 12:29 PM, CNA 1 stated, a resident cursing at other people is verbal abuse. CNA 1 stated, "It is very offensive if the other resident hears it." During an interview with the Laundry Personnel FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5MEJ11 Facility ID: CA950000062 If continuation sheet 9 of 11 PRINTED: 05/13/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055376 (X3) DATE SURVEY COMPLETED 08/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HUNTINGTON DRIVE HEALTH AND REHABILITATION CENTER 400 W Huntington Dr Arcadia, CA 91007 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE (LDP) on 8/6/2024 at 1:20 PM, LDP stated "on 7/31/2024, she witnessed Resident 1 being yelled and cursed in Spanish by Resident 2 by saying, "Move, you son of a b_ _ _ ch." LDP stated she heard the same cursing words that MRA heard inside Resident 1's room. LDP stated this was considered verbal abuse. LDP stated she always hear Resident 2 insult and say bad words to Resident 1 every day. LDP stated she did not report the abuse incidents because she was scared to get in trouble. During an interview with the Maintenance Supervisor (MTS) on 8/6/2024 at 1:38 PM, MTS stated it is considered "verbal abuse if a resident curses at another resident. MTS stated, "We have to report it (verbal abuse). I don't think it is okay to be mean to someone else. I will really feel bad if I or my loved ones would hear it." During an interview with the LDP on 8/6/2024, at 1:28 PM, LDP stated according to the inservice she attended, abuse should be reported. LDP stated she was not aware of the timeline for abuse reporting. During a concurrent review of Resident 2's SBAR, dated 7/31/2024, and interview with the Director of Nursing (DON) on 8/6/2024, at 1:48 PM, the DON stated the SBAR indicated Resident 2 was verbally aggressive and was cursing her roommate. The DON stated, "Hearing cursing words is considered verbal abuse because it is hurtful towards the other person." During an interview with Director of Nursing (DON) on 8/6/2024, at 2:09 PM, the DON stated, it was important to report abuse to keep the resident safe and prevent another incident." The DON stated abuse should be reported to the State agency, Ombudsman and local law enforcement within 2 hours according to facility FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5MEJ11 Facility ID: CA950000062 If continuation sheet 10 of 11 PRINTED: 05/13/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055376 (X3) DATE SURVEY COMPLETED 08/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HUNTINGTON DRIVE HEALTH AND REHABILITATION CENTER 400 W Huntington Dr Arcadia, CA 91007 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE policy. During a review of the facility's Policy and Procedure (P&P) titled, "Abuse, Neglect, Exploitation and Misappropriation- Reporting and Investigating," revised 9/2022, the P&P indicated if resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. P&P indicated the Administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies: a. The state licensing /certification agency responsible for surveying/licensing the facility b. The local/state ombudsman ... ... e. Law enforcement officials. The P&P also indicated, "Immediately" is defined as within 2 hours of an allegation involving abuse or result in serious bodily injury. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5MEJ11 Facility ID: CA950000062 If continuation sheet 11 of 11