Laguna Hills Health And Rehabilitation Center
Inspection Findings
F-Tag F600
F-F600
.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 5 of 5 056110
F-Tag F609
F-F609
.
Level of Harm - Minimal harm or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 3 of 5 056110 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056110 B. Wing 07/01/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Laguna Hills Health and Rehabilitation Center 24452 Health Center Drive Laguna Hills, CA 92653
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)
F 0609 Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 41941
Residents Affected - Few Based on interview, medical record review, facility document 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 CNA 1 witnessed CNA 5 verbally abusive toward Resident 1 and failed to report it to the supervisor during her shift. This failure had the potential for delaying the assessment and provision of care for Resident 1 and not protecting the resident for further abuse.
Findings:
Review of the facility's P&P titled Abuse, Neglect, Exploitation, or Misappropriation - Reporting and Investigating revised 9/2022 showed if resident abuse is suspected, the suspicion must be reported to the administrator and to other officials immediately. The P&P defined immediately as within two hours of an allegation regarding abuse.
Review of the facility's SOC 341 Report of Suspected Dependent Adult/Elder Abuse dated 5/29/24, showed CNA 1 witnessed CNA 5 calledResident 1 names and place a sheet over Resident 1's head.
Review of the facility's investigative summary dated 6/3/24, showed an interview was conducted with CNA 1 at 1700 hours. The facility's summary showed CNA 1 stated CNA 5 told her that she managed the confused/combative residents by flicking them softly, not hard enough to leave a mark and she did it when no one was around. During the interview, CNA 1 stated when preparing to enter Resident 1's room, CNA 5 told her that Resident 1 yelled insulting the facility's staff such as you're fat, you're ugly, and you need to lose weight. CNA 1 stated Resident 1 became combative while care was being provided and CNA 5 began calling Resident 1 fat, ugly, and told the resident that she needed to lose weight. CNA 1 stated when Resident 1 was placed in bed, CNA 5 covered Resident 1 with a sheet entirely from head to toe including her face and left it like that.
Medical record review for Resident 1 was initiated on 6/5/24. Resident 1 was admitted to the facility on [DATE REDACTED].
Review of Resident 1's H&P examination dated 12/26/23, showed Resident 1 did not have the capacity to understand and make medical decisions. Resident 1 had diagnoses including dementia, anxiety, and depression.
Review of Resident 1's MDS dated [DATE REDACTED], showed the resident had severe cognitive impairment.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 4 of 5 056110 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056110 B. Wing 07/01/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Laguna Hills Health and Rehabilitation Center 24452 Health Center Drive Laguna Hills, CA 92653
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)
F 0609 On 6/5/24 at 1155 hours, a telephone interview was conducted with CNA 1. CNA 1 stated she was a new employee and shadowed CNA 5 on night shift as part of her orientation. CNA 1 stated at the start of the shift, Level of Harm - Minimal harm or CNA 5 told her thatshe flicked some of the combative residents but was careful not to leave a mark. CNA 5 potential for actual harm told her that she only did it to the non-alert residents because they could not go back and tell anyone. CNA 1 stated CNA 5 told her not to tell anyone because it was against the law. CNA 1 stated they started their Residents Affected - Few rounds at about 0430 hours, and went to Resident 1's room last because CNA 5 told her that she did not want to deal with Resident 1. CNA 5 stated they went to Resident 1's room at around 0500 hours, to change Resident 1's brief and get the resident ready for the next shift. CNA 1 stated when they entered Resident 1's room, there was feces all over the place. CNA 1 stated CNA 5 told Resident 1 that it was disgusting, she was disgusting, and her son should be told about it. CNA 1 stated CNA 5 was cleaning Resident 1's nose and Resident 1 screamed but became silent after that. CNA 1 stated CNA 5 told Resident 1 that she was fat, not pretty, and needed to lose weight. CNA 1 stated prior to exiting the room, CNA 5 put a sheet over Resident 1's head then left the room. CNA 1 stated it made her nervous, but she was being trained by a CNA who had more experience than her. CNA 1 stated she did not know if it was qualified as abuse at the time. CNA 1 stated she texted the DSD in the morning of 5/29/24, and requested to speak with her later that day.
On 6/5/24 at 0950 hours, an interview was conducted with the DSD. The DSD stated CNA 1 had texted her
on 5/29/24 at 0730 hours, and requested a meeting with her about an incident that happened that night but did not explain what it was about. The DSD stated CNA 1 was coming in that day to attend a skills fair from 0800 hours to 1500 hours. The DSD stated CNA 1 spoke with her later in the day on 5/29/24, but was not sure of the exact time. The DSD stated CNA 1 told her that she was shadowing CNA 5 on the night shift and heard CNA 5 told Resident 1 that she was fat and ugly. The DSD stated, I immediately called the Administrator and told him about the abuse allegations.
On 6/5/24 at 0830 hours, an interview and concurrent record review was conducted with the Administrator.
The Administrator stated he was notified by the DSD of the incident on 5/29/24 at approximately 1500 hours.
The Administrator stated CNA 1 was interviewed about the incident with the DON, DSD, and himself. The Administrator stated CNA 1's story was consistent. The Administrator stated CNA 1 was suspended because
she did not intervene and did not notify the supervisor immediately. The Administrator stated CNA 1 was required to go through abuse training again.
Cross reference to