complaint·October 26, 2023

9099C-1.. Staff did not prevent resident from being sexually assaulted. Complaint alleges that (R1) was sexually assaulted on 4/15/23 by another resident (R2) and that resident (R2) was no longer allowed at the facility due to previous behaviors. Staff interviews revealed that while doing rounds on 4/15/23, at approximately 5:00 am, (2) staff found (R2) laying naked on top of (R1) in (R1's) bed. Interviews confirmed that (R1) was observed to be wearing a diaper and a nightgown, and there was a third resident (R3) in the room sitting in a chair. Staff interviews revealed that (R3) was (R2’s) girlfriend and would walk around the facility together. The incident report submitted to the Department states that on 4/15/23, at approximately 7:00 am, (R2) was observed without clothes laying on top of (R1), who was fully clothed, and the residents were separated and (R2) was returned back to his room. The facility incident report notes law enforcement was notified and later came to the facility to investigate and (R2) was transferred to the hospital for further evaluation and had remained there as of 4/17/23 when the report was submitted. The report notes that (R2)'s conservator contacted facility staff on 4/17/23 to advise that (R2) would not be returning to the facility due to his behavior. Staff interviews confirmed that (R2) "was always up during the NOC shift", and would frequently try and exit to the patio courtyard as the alarms would go off and go in other resident rooms. Staff interviews revealed "(R2) always hit on different women from the start of NOC shift until breakfast time", with one staff stating, "I've seen him (R2) with other women- he was just laying there, cuddling". Staff interviews indicated that (R2) was "more physically aggressive”, would push other residents and hit them, and his behaviors were not taken seriously by the Administrator at the time, commenting (R2) was "sent out constantly but would return" and would walk around naked on a regular basis, taking (3-4) staff to get (R2) out of another resident's room. Resident (R2) moved to community in March 2020 with a diagnosis of Dementia, and other conditions and was conserved. (R2's) care plan, dated June 2022, says (R2) needs maximum assistance in redirection due to elopement risk and wandering throughout the building, in residents’ rooms and exit seeking during the day. The care plan also notes (R2) needs maximum assistance to maintain safe and appropriate interactions and due to severe sleep disturbances caused by sun downing. cont on 9099C-2.. 9009C-2... (R2's) Physician's Report, dated 2/22/23 states resident is confused, disoriented, has inappropriate behavior and is aggressive. Electronic charting notes entered by the Administrator and Resident Care Coordinator note that (R2) was showing an outburst and inappropriate behavior on 3/13/23, agitation and change in baseline on 3/15/23 and showed more agitation and a change in condition on 3/29/23. An updated LIC602 was obtained on 3/27/23 noting resident is confused, disoriented, shows aggressive/wandering/sun downing behavior and inappropriate behavior, has bladder impairment, and is now not able to feed himself or do any Activities of Daily Living (ADL's). The Ombudsman investigated the incident and contacted the police department for their report and concluded that the case did not meet criteria for a criminal case due to (R2) having a diagnosis of Dementia and suffering a stroke (3) weeks prior causing him to be more aggressive. The police report based their findings on the Ombudsman's findings. LPA reviewed a copy of a fire (911) incident report, dated 4/15/23, noting facility staff reported (R2's) behavior to be of concern for the safety of other residents as (R2) attempted to interact inappropriately with other residents in addition to (R1). On 4/16/23, (R2) was sent to the Emergency Room for a mental evaluation and was placed on hold due to his pattern of behavior within the community and did not return to the facility. LPA conducted a case management inspection on 4/21/23, after receiving the incident report on 4/17/23. LPA attempted to speak to resident (R1) in the presence of Administrator, but resident was not able to speak and be understood but was in a pleasant mood. LPA did not observe (R1) to show any bruises on her face or lower legs that were not covered by clothing. LPA observed (R1) able to move herself in a wheelchair. The Administrator at the time did not discuss any concerns with the LPA regarding either resident (R1/R2) or mention that another resident (R4) had sustained an unexplained head injury during the same shift, was sent to the Emergency Room and received multiple staples on her head. Staff interviews and interviews with responsible persons for (R4) revealed that (R4) and (R2) may have entered into a altercation and (R4) was hit on the head or fell and hit her head. The incident report submitted for (R4) states that she was found on the floor in her room, at approximately 7:00 am, on 4/15/23, with blood on her head but could not recall how the injury happened. Discharge papers show (R4) was seen in the ER on 4/15/23 for head pain and was diagnosed with head trauma, laceration of head and UTI symptoms, and the laceration was treated with (4) staples. cont on 9099C-3.... 9099C-3.. One staff stated (R1) has "no way to consent since she is non-verbal" and she "can't defend herself". Another staff stated "(R1) mumbles and says phrases only" and would not have been able to consent to (R2) being in her bed. Two staff stated (R1) appeared “traumatized for sure”, (R1's) face had a different color and she had her head down after she and the other staff pulled (R2) off of (R1). Based on information obtained, LPA finds the allegation to be SUBSTANTIATED- A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Allegation: Staff did not seek medical attention for resident in a timely manner. Complaint alleges that (R1) wasn’t examined following the incident on 4/15/23 until 4/20/23 when the facilitiy's Nurse Practitioner (NP) came to the facility. The responsible person for (R1) stated that when informed of the incident on 4/15/23, she asked facility staff if (R1) had been taken to the hospital to be checked out and was told she had not been. This family member stated she then demanded that (R1) get checked out, but (R1) wasn’t check out until 4/20/23 by the facilities NP. The family member stated on 6/10/23, she called the NP last week and left a message, but she had not heard back. Charting Incident notes for (R1) document the incident on 4/15/23 (Saturday) and on 4/16/23 notes state there were no changes observed for (R1); on 4/17/23, notes say NP was contacted and would be coming out to “check (R1)” and (R1) has been doing good and is still wandering around the facility. On 4/18/23 and 4/19/23, additional notes were entered that there were no changes. (R1) did not receive any medical attention until 4/20/23 when NP visited the community. Notes say: “NP checked (R1) from head to toe and all skin is good and there are no changes for (R1)”. The NP stated he believes (R1) was on hospice at the time, was frail, and could not provide any other information. A hospice nurse stated that the incident was never confirmed with him but (R1) was not under hospice care at the time. Based on information obtained, LPA finds the allegation to be SUBSTANTIATED- A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. cont on 9099C-4... 9099C-4... Allegation: Staff are not providing resident's authorized representative with copies of incident reports. Complaint alleges (R1's) family member requested copies of all incident reports with (R1) and she hasn't received any reports. (R1's) family member stated that (R1) has gone to the Emergency Room 4-5 times in the last (8) years while living at the facility. The family member stated she spoke with a manager to request the reports, and the reports were not made available to her. LPA discussed this request with the current Administrator who indicated that this family member would reach out to the Administrator regarding why she is not currently not in contact with the facility. The current Administrator stated she has not heard from this family member for a while. Based on information obtained, LPA finds the allegation to be SUBSTANTIATED- A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Per California Code of Regulations, Title 22, Division 6, Chapter 8, the following (3) citations are issued on the 9099-D pages. Exit interview. Copy of report and appeal rights provided. 9099A-C-1... LPA reviewed the incident report (LIC624) for an incident occurring on 2/11/22- at 10:30 am, when (R1) found on the floor during staff rounds. The LIC624 notes (R1) had no visible injuries but was sent to ER and had remained in the hospital as of 2/14/22, when the incident report was completed. The LIC624 notes this family member was notified. A second family member of (R1) indicated there were several incidences of (R1) having a fall and recently she fell last month in September twice, between Sept 6 and 10th. Based on information obtained, LPA finds this allegation to be UNSUBSTANTIATED- meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Allegation: Resident had an unexplained fall sustaining injuries due to staff negligence. Complaint states that before (R1) fell and fractured her hip, she had another unexplained fall and staff do not know what happened. There are no other details provided. A LIC624 was submitted for an incident on 2/11/22- 10:30 am where (R1)found on the floor during rounds with out any visible injuries. (R1) was transported to the hospital and remained there through the time the LIC624 was submitted on 2/14/22- 3+days in the hospital. This person indicated that the assigned hospice nurse found (R1) when she fell in Feb 2022. One family member stated (R1) had some bruising on her face and would provide the Department with photos early in the investigation, but they were not provided. A second family member indicated there were several incidences of (R1) having a fall and recently fell last month twice in September, between Sept 6 and 10th. This family member stated that for the first fall, (R1) was sent to ER and released the same day for no injuries; however, the second time, (R1) fell in the lunch room and was by herself. This family member stated the facility thought it was a "harder fall" and had (R1) sent out to the Emergency Room for CT scans and additional tests , stating "they were more concerned about the second fall". cont on 9099A-C-2... 9099A-C-2... Allegation: Staff did not prevent a resident from engaging in inappropriate behaviors. Complaint alleges that when (R1’s) family member was visiting she heard (R1) screaming and observed another resident (unknown name) attacking her mom on the floor. One of (R1's) family members stated there was another time when (R1) "was attacked by another resident" around 2021-2022. This person stated that the nurse from hospice was there and he had called her due to (R1) having some bruising on her face. Photos were not provided to the Department as previously agreed to. The LIC624 submitted for the incident on 11/17/21 was completed 11/18/21 and involved (R1) and (R5). The incident report states that around 3:00 pm, staff heard (R1) shouting for help and went to assess the situation and found (R1) on the floor and (R5) was kicking (R1). Staff called for a shift manager and both staff were able to separate the residents. Both residents were sent to the ER and (R1) returned to the community with no changes. (R5) remained in the hospital as of when the report was completed on 11/18/21. A second family member confirmed that (R1) was on and off of hospice several times since moving to the facility in 2014 and that she had a lot of falls. This family member stated that (R1)would "walk and walk" prior to moving to the community and liked to be on her feet. Based on information obtained, LPA finds this allegation to be UNSUBSTANTIATED- meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview. Copy of report provided. 9099A2-C-1... One staff stated the incident with (R1) and (R2) was "reported the day after" and that they called (R1's) family and left a message for both family members who were alternating as POA's. This staff asserted "neither one answered", but "I know for a fact that I personally called both of them- they called back after my shift ended". Resident charting notes do not indicate that (R1’s) responsible person(s) was contacted immediately following the incident; however, the LIC624 (dated 4/17/23) states that residents’ responsible parties and primary care physician's were notified. The Administrator and RCC agreed to provide staff training on ensuring that notes are entered every time staff makes an attempt to contact the responsible person. Based on information obtained, LPA finds this allegation to be UNFOUNDED- meaning that the allegation was false, could not have happened and/or is without reasonable basis. Exit interview. Copy of report provided to Administrator.