Other·November 27, 2019

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 survey for the investigation of one (1) complaint #CA00639230 and one (1) facility reported incident #CA00638944. Representing the Department of Public Health: Health Facilities Evaluator Nurse, 38669 The inspection was limited to the specific complaint and facility reported incident investigated and does not represent the findings of a full inspection of the facility.

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

F600 12/03/2019 §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: Based on interviews and review of facility documents and policy, the facility failed to ensure 1of 3 sampled residents (Resident 1) 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: WPL111 Facility ID: CA030000024 If continuation sheet 1 of 7 PRINTED: 05/14/2026 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: _______________ 055776 (X3) DATE SURVEY COMPLETED 11/15/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WESTVIEW HEALTHCARE CENTER 12225 Shale Ridge Lane Auburn, CA 95602 (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 was free from sexual abuse when Certified Nurse Assistant 1 (CNA 1) forced Resident 1 to perform oral sex. This failure resulted in Resident 1 experiencing emotional distress as evidenced by crying, increased anxiety, fear, and depression. Findings: A review of the facility reported incident, dated 5/24/19 to the Department, revealed an incident involving Resident 1 and the CNA 1. The incident occurred a week prior, on 5/16/19. The report reflected Resident 1 reported that CNA 1 grabbed her head and forced her to place her mouth on his genitals. A review of an undated Resident Face Sheet indicated Resident 1 was admitted to the facility late 2017 with diagnoses including difficulty walking, history of falling, bipolar disorder (a condition causing mood swings), major depressive disorder, and anxiety disorder. Resident 1's Minimum Data Set (MDS, an assessment tool) dated 3/15/19, indicated, Resident 1 had no memory problems. Resident 1's Care Plan required staff to assist with bathing. A review of Resident 1's Psychiatry Note, dated 5/21/19, described Resident 1 as having "...some increase in anxiety...but seems vague about the cause." Review of Resident 1's 'Nursing Progress Note', dated 5/23/19 indicated, [Resident 1] reported to [CNA 2] that after CNA 1 gave her a shower, the CNA 1 "showed [Resident 1] his private part." Review of the 5/23/19 Police Report indicated the incident occurred on "5/16/19 at 1400 [2 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WPL111 Facility ID: CA030000024 If continuation sheet 2 of 7 PRINTED: 05/14/2026 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: _______________ 055776 (X3) DATE SURVEY COMPLETED 11/15/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WESTVIEW HEALTHCARE CENTER 12225 Shale Ridge Lane Auburn, CA 95602 (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 p.m.]". The Police Report indicated Resident 1's statement to police was that CNA 1 assisted her in the shower, made sexual remarks about her figure, repeatedly returned to her room four times over the course of the night and on the last visit forced Resident 1 to perform oral sex. During the statement to the police Resident 1 stated she had nightmares that night and wondered why the incident happened. She stated she has become very scared of CNA 1. During the interview, Resident 1 was noted to be, "visibly upset and at times cried." Another Psychiatry Note, dated 5/24/19, described Resident 1 as, "Pt [patient] is highly agitated after recounting a recent sexual assault that is still under investigation...Pt was withdrawn and tearful." An interview was attempted with Resident 1 on 5/24/19 at 2:37 p.m., after a formal introduction from facility staff. Resident 1 declined to be interviewed and stated, "I don't want to speak with you...Thank you, please go away." During an interview with a housekeeper (HK) on 5/24/19 at 3:55 pm, the HK recalled a conversation she had with the CNA 1 on the first day she met him. The HK believed he tried to intimidate her. The HK stated CNA 1 "made inappropriate comments while I was on my knees scrubbing the floor, he said, 'It's sexy to see a woman down on all fours.' It caught me off guard. It made me uncomfortable. The [CNA 1] would follow me around. I told my boss in April. They told me they are not going to fire him. They moved [CNA 1] to Station 1." During an interview with Licensed Nurse 2 (LN 2) on 5/24/19 at 5:27 p.m., the LN 2 stated, "Last night, [Resident 1] told me that on her last shower day [5/16/19], [CNA 1] watched her as FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WPL111 Facility ID: CA030000024 If continuation sheet 3 of 7 PRINTED: 05/14/2026 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: _______________ 055776 (X3) DATE SURVEY COMPLETED 11/15/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WESTVIEW HEALTHCARE CENTER 12225 Shale Ridge Lane Auburn, CA 95602 (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 she showered and made a comment, 'You have a nice figure for someone your age.' He whispered something in her ear but she couldn't hear him and then he showed her his penis. He came back to her a total of 4 times that evening...The third time she saw it [his penis]...The fourth time he came back, he moved her tray table...positioned himself at the head of her bed and placed his hand behind her head and her back...[CNA 1] was moving her head in motion on his penis. He came [ejaculated]. He wiped her mouth off with a wipe and left...It's very concerning. I wrote on his write up that he needs to complete the sexual harassment training with the Director of Staff Development (DSD). That was about a month ago. She should have followed up." Review of the facility Investigative Report for this incident, dated 5/28/19, indicated, "CNA #1 [CNA 1] was already suspended pending the previous allegation...Based on the investigation, the facility determined that the incident could have occurred and the facility decided to sever its relationship with CNA #1." During an interview with the CNA 2 on 5/29/19 at 8:15 a.m., the CNA 2 stated, "I had [Resident 1] in the shower room...[Resident 1] started crying. I asked what happened and she said that [CNA 1] should be fired...She said...when she got back to the room [CNA 1] pulled his private parts out and showed them to her...She doesn't make things up. She had so many details...I don't see [Resident 1] making all this up." During an interview with the Social Services Director (SSD) on 5/29/19 at 9:10 a.m., the SSD stated, "This was the second complaint against [CNA 1]...Resident 1 is just a little overwhelmed right now." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WPL111 Facility ID: CA030000024 If continuation sheet 4 of 7 PRINTED: 05/14/2026 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: _______________ 055776 (X3) DATE SURVEY COMPLETED 11/15/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WESTVIEW HEALTHCARE CENTER 12225 Shale Ridge Lane Auburn, CA 95602 (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 the DSD on 5/29/19 at 9:40 a.m., the DSD confirmed [CNA 1] had worked at the facility since 3/26/19. The DSD confirmed she did not follow the recommendation from her colleague and verified [CNA 1] "had received abuse and sexual harassment training during orientation only" and she did not provide the additional training that the LN 2 recommended CNA 1 take before returning to work. A review of Resident 1's Psychiatry Note, dated 5/29/19, described Resident 1 as being " ...still extremely agitated. Pt is tearful, withdrawn..." During an interview with the Administrator (ADM) on 5/29/19 at 10:20 a.m., the ADM verified he had not received a statement from Resident 1's roommate but verified he had terminated [CNA 1's] employment based on all interviews and findings. During an interview with the CNA 1 on 5/30/19 at 12:22 p.m., the CNA 1 stated, "I did not expose myself to that woman. I [was just hired] before all this happened. All these allegations against me...I ain't never had this before in my life. I've been a CNA for 6 years and I have had more allegations on me in the last month and a half." Review of Resident 1's Psychiatry Note, dated 5/30/19, described Resident 1 as, "...still significantly emotionally impaired and agitated...[with] expressions of guilt and shame." During an interview with Resident 1's roommate, Resident 5, on 5/31/19 at 12:15 p.m., Resident 5 recalled the CNA 1 coming into their room on 5/16/19. Resident 5 stated she was eavesdropping on Resident 1 and the CNA 1 and heard the CNA 1 whispering and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WPL111 Facility ID: CA030000024 If continuation sheet 5 of 7 PRINTED: 05/14/2026 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: _______________ 055776 (X3) DATE SURVEY COMPLETED 11/15/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WESTVIEW HEALTHCARE CENTER 12225 Shale Ridge Lane Auburn, CA 95602 (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 telling Resident 1, "[Resident 1] 'Don't tell nobody nothing.' He didn't say anything else." Review of Resident 1's Physician Orders, dated 6/1/19, indicated an order to double Resident 1's Ativan (medication to treat anxiety) from 0.25 milligrams (mg, unit of measurement) to 0.5 mg every 12 hours for anxiety. Review of Resident 1's Practitioner Progress Notes, dated 6/5/19, indicated Resident 1 "had previously been doing well and was in good spirits ...[Resident 1] is feeling depressed and is lying in bed and not nearly as active ... [Resident 1] still has nightmares and is grateful for the Ativan." Review of Resident 1's Physician Orders, dated 6/6/19, indicated an order to double Resident 1's Ativan once again, from 0.5 mg to 1 mg every 12 hours for anxiety. Review of Resident 1's Physician Progress Note, dated 6/10/19, indicated Resident 1 relayed episode of abuse and was "having trouble concentrating ...[Resident 1] starts to think about the episode and her mind gets diverted." Review of Resident 1's Practitioner Progress Notes, dated 8/6/19, indicated Resident 1 "[Resident 1] is feeling intermittently anxious and depressed...She continues to have nightmares and sudden feeling of panic...She anticipates having to...testify...[against the CNA 1] which she would like to do but also finds distressing." Review of a facility policy titled, 'Abuse prevention Program' revised December 2016, indicated, "Our residents have the right to be free from abuse...This includes...mental, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WPL111 Facility ID: CA030000024 If continuation sheet 6 of 7 PRINTED: 05/14/2026 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: _______________ 055776 (X3) DATE SURVEY COMPLETED 11/15/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WESTVIEW HEALTHCARE CENTER 12225 Shale Ridge Lane Auburn, CA 95602 (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 sexual, or physical abuse...As part of the resident abuse prevention, the administration will...Protect our residents from abuse by anyone including...facility staff." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WPL111 Facility ID: CA030000024 If continuation sheet 7 of 7