Health inspection·March 12, 2024

The following reflects the findings of the California Department of Public Health during the investigation of: Re-certification Survey Event ID: QS9Y11 Representing the Department, HFEN #47369 State Citation B was written. 483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: (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. 1418.91(a) A long-term health care facility shall report all incidents of alleged abuse or suspected abuse of a resident of the facility to the department immediately, or within 24 hours. (b) A failure to comply with the requirements of this section shall be a class "B" violation. On 1/22/24 at 8:00 a.m., an unannounced visit was conducted at the facility to conduct a Re-certification survey. The department determined the facility failed to implement its abuse program for Resident 45 when Resident 45 was involved in sexual interactions with another resident (Resident 36) who had a history of sexually inappropriate behavior with staff and residents, and the facility did not report the incidents as possible sexual abuse. These failures led to three instances of possible sexual abuse on 12/15/23; 12/17/23; and 12/23/23 not being reported; and resulted in the State Agency being unaware of the potential danger to Resident 45. A review of Resident 45's Admission Record indicated Resident 45 was admitted to the facility with diagnoses which included dementia (the loss of cognitive functioning - thinking, remembering, and reasoning - to such an extent that it interferes with a person's daily life and activities). A review of Resident 36's Admission Record indicated Resident 36 was admitted to the facility with diagnoses which did not include dementia. A review of Resident 36's clinical records titled, "Progress Notes," ranging 12/15/23 through 1/8/24 indicated Resident 36's behavior with other residents as follows: " ...12/15/2023 11:26 [AM] Note Text: CNA [certified nursing assistant] reported to writer that she witness [sic] [Resident 36] in female peers room touching and kissing peer ..." " ...12/19/2023 17:00 [5 PM] patient noted following female peer around facility. patient [sic] unreceptive to redirection. patient stated " im [sic] not gonna stop, do you know how many times ive [sic] kissed her?... attempted to counsel patient however patient continued to be non-redirectable ..." " ...12/20/2023 16:15 [4:15 PM] ... pt [Patient] was observed attempting to kiss [Resident 45] on the cheek ..." " ...12/23/2023 14:49 [2:49 PM] ...patient observed kissing and touching peer. staff attempted to provide redirection and counsel however patient became agitated and was unreceptive. patient asked, " how am i [sic] supposed to get a girlfriend in this place then." writer again reminded that boundaries and personal space should be maintained and respected. patient [sic] did not respond ..." A review of Resident 45's clinical records titled, "Progress Notes," ranging 12/15/23 through 12/23/23 indicated as follows: " ...12/15/2023 11:26 [AM] ...CNA reported that a male resident was in room with patient and both patients were seen kissing. Writer asked male resident to leave the room ..." " ...12/17/23 17:46 [5:46 PM] ... Resident caught kissing [Resident 36] in front of the nurses station at dinner time. No inappropriate touching with hands. Female resident is confused and both residents were separated." " ...12/23/23 14:49 [2:49 PM] ... patient observed kissing peer. patient consenting however patient is not self-responsible ..." During an interview with the Long-Term Care (LTC) Ombudsman (an advocate for residents in long term care facilities) on 1/25/24, at 9:18 AM, the LTC Ombudsman stated she would expect to be notified if there were issues with sexually inappropriate behavior and stated she had not been notified of the interactions between Resident 45 and Resident 36. The LTC Ombudsman further stated that sexually inappropriate behavior was very serious. During an interview with the Social Services Assistant (SSA), on 1/25/24, at 9:26 AM, the SSA stated she was not aware if there should have been any follow-up regarding the sexual interactions between Resident 45 and Resident 36 because Resident 45 was not complaining about Resident 36 doing anything to her. During an interview with Resident 45, on 1/25/24, at 9:47 AM, Resident 45 was unable to respond to her name and stared off in the distance. During an interview with CNA 3, on 1/25/24, at 9:56 AM, CNA 3 stated Resident 36 was flirtatious and "hands on grabby" with Resident 45. CNA 3 stated that Resident 45 has told him "no" in the past. CNA 3 explained Resident 45 would not remember an incident that occurred the day before and she did not think Resident 45 would say anything. CNA 3 stated Resident 45 did not know Resident 36's name. CNA 3 further stated she did not think Resident 45 was aware of her actions, stating Resident 45 will do something and then forget. CNA 3 further stated Resident 36 was aware of his actions. CNA 3 explained she has witnessed Resident 45 and Resident 36 when Resident 45 was not happy with Resident 36's presence. CNA further explained she reported the incident to the nurse, stating it had been about month ago on the PM (evening) shift, and stated she was not interviewed regarding the incident. During an interview with licensed nurse (LN) 5, on 1/25/24, at 10:05 AM, LN 5 stated she thought Resident 45 was vulnerable and did not think Resident 45 had the capacity to consent to sexual interaction. LN 5 stated she had heard of some incidents between Resident 45 and Resident 36 but was not aware if the incidents had been reported to the LTC Ombudsman or the State Agency. During an interview with LN 2, on 1/25/24, at 10:11 AM, LN 2 stated Resident 45 did not have the capacity to make decisions, "She is pretty forgetful." LN 2 further stated Resident 45 was alert and oriented times 1 or 2, explaining that Resident 45 was oriented to self and where she was, but not to what was going on. LN 2 explained she had asked the Director of Nursing (DON) and the Administrator (ADM) if the sexual interactions should be reported. LN 2 further explained the DON and ADM told her the sexual interactions did not have to be reported because Resident 45 was engaging and welcoming the behavior from Resident 36. During an interview with the Psychiatric Nurse Practitioner (PNP), on 1/25/24, at 11:34 AM, the PNP stated the facility contacted her regarding Resident 45 because Resident 45's daughter wanted her to be assessed due to possible inappropriate contact with a male resident (Resident 36). The PNP explained Resident 36 was his own responsible party, and it had been reported to her on 12/30/23 that Resident 30 was being sexual inappropriate towards females. The PNP further explained she went to the facility on 1/5/24 and evaluated Resident 36 and ordered psychotherapy for him due to the risk of sexually inappropriate behavior. The PNP stated she tried to explain to Resident 36 that he could not touch people with dementia, stating Resident 36 got angry but he listened. Regarding Resident 45, the PNP stated she did not have the capacity to consent to sexual activity, she had dementia. The PNP explained Resident 45 was confused and her cognition had changed. The PNP further explained it was a natural progression of Resident 45's dementia. During an interview with Family Friend (FF) 1, on 1/25/24, at 2:48 PM, FF 1 stated she had been Resident 45's best friend for 35 years and she regularly visits Resident 45. FF 1 stated during a visit at Christmas time Resident 45 had stated to her there were a couple of "fellows" making advances and Resident 45 was upset about it and wanted to be left alone and did not appreciate it. FF 1 further explained Resident 45 had male friends in the past, but it was never anything physical and that was her preference. During an interview with the Medical Director (MD), on 1/25/24, at 3:03 PM, the MD stated Resident 45's dementia would impact her informed decision making. The MD explained there should be be consent from both parties wanting to engage in sexual interactions, and if one of them lacked the capacity to make informed consent, that was a concern. The MD stated he would expect staff to inform him if there was a concern regarding inappropriate sexual interactions between residents, that it was his role as Medical Director to oversee the quality of care at the facility. During an interview with the Administrator (ADM) and the Director of Nurses (DON), on 1/25/24, at 3:38 PM, the ADM stated, "If the activity is consensual and both parties participate and are agreeable and the responsible party agrees...have not had that extensive sexual contact." Regarding capacity for Resident 45 to consent to sexual interactions, the DON stated they would look at the residents Brief Interview for Mental Status (BIMS) and look at their diagnoses to see if they were physically able and cognitively able to make that decision. The DON stated, "...[Resident 45] is confused, so is our male resident...I think it is not so much a cognitive decision as a natural instinct or impulse...She is...kind and very loving person..." The DON stated she did not see Resident 45 avoiding physical contact. The ADM stated they had not seen signs that Resident 45 did not want to engage in the sexual interactions with Resident 36. The DON stated she did not think Resident 45 had the capacity to give consent. The ADM and DON confirmed the incidents were not reported as potential abuse. During an interview with the ADM, on 1/30/24, at 5:32 PM, the ADM stated the purpose of reporting abuse was the protection of residents, to keep them safe. The ADM further stated if there was abuse it should be reported. A review of the facility's policy titled, "Freedom From Abuse, Neglect and Exploitation," dated 11/2017, indicated, "Purpose: To keep residents free from abuse, neglect, and corporal punishment of any kind by any person...The facility will provide a safe environment and protect residents from abuse...For allegations of abuse, the facility will...Immediately implement safeguards to prevent further potential abuse...Immediately report the allegation to appropriate authorities...Conduct a thorough investigation of the allegation...Document and report the result of the investigation of the allegation...Sexual Abuse...Non-consensual sexual contact of any type with a resident who appears to want the contact to occur, but lacks the cognitive ability to consent...Investigations of an allegation of sexual abuse will start with a determination of whether the sexual activity was consensual or not, taking into consideration the cognitive ability of the resident to consent...Residents without the ability consent will not engage in sexual activity..." Therefore, the department determined the facility failed to implement its abuse program for Resident 45 when Resident 45 was involved in sexual interactions with another resident (Resident 36) who had a history of sexually inappropriate behavior with staff and residents, and the facility did not report the incidents as possible sexual abuse. These failures led to three instances of possible sexual abuse on 12/15/23; 12/17/23; and 12/23/23 not being reported; and resulted in the State Agency being unaware of the potential danger to Resident 45. These violations, jointly, separately, or in any combination, had a direct or immediate relationship to the health, safety, and security of residents.