Health inspection·July 25, 2024

F 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement its abuse policy and procedure for one of three (3) sampled residents (Resident 1) by failing to thoroughly investigate an allegation of sexual abuse (non-consensual sexual contact of any type with a resident. Residents Affected - Few This deficient practice had the potential to place Resident 1 at risk for elder abuse. Findings: A review of Resident 1's admission Record indicated resident was admitted on [DATE] with the diagnoses of dementia (long term and often gradual decrease in the ability to think and remember severe enough to affect a person's daily functioning) and aphasia (a language disorder that affects how a resident communicates). A review of Resident 1's History and Physical, dated 6/20/2024, indicated resident has the capacity to understand and make decisions. A review of Resident 1's Minimum Data Set (MDS, a standardized care screening and assessment tool), dated 6/26/2024, indicated resident was moderately impaired with cognitive ((mental action or process of acquiring knowledge and understanding) skills for daily decision making. MDS also indicated Resident 1 required partial/moderate assistance (helper does less than half the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) with eating and oral hygiene. MDS indicated Resident 1 required substantial/maximal assistance (helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort) with toileting hygiene, shower/bathe self, upper body dressing, lower body dressing, putting on/taking off footwear and personal hygiene. A review of Resident 1's Situation, Background, Assessment, and Recommendation (SBAR, a structured communication framework that can help teams share information about the resident's condition), dated 7/15/2024, indicated resident stated that she was felt up (to touch or fondle someone for sexual pleasure) by a male staff member and it occurred in the nighttime/ early morning on Saturday 7/13/24. A review of the Facility's Staff Assignment, dated 7/12/24 3 PM to 11 PM shift, indicated Certified Nursing Assistant 1 (CNA 1) was a male staff member assigned to Resident 1. During a concurrent record review of the facility's staff assignment on 7/12/2024 and interview on 7/25/2024 at 11:36 AM, the Director of Nursing (DON) confirmed that CNA 1 was assigned to Resident 1 on 7/12/2024 during the 3 PM to 11 PM shift. The DON stated the facility should have looked into Page 1 of 2 055480 055480 07/25/2024 The Californian Pasadena Healthcare 120 Bellefontaine Street Pasadena, CA 91105

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the staffing on 7/12/2024 at 3 PM to 11 PM shift since Resident 1 mentioned it was a male staff member at nighttime. The DON also stated that the facility should have suspended CNA 1 until further investigation for the safety of Resident 1 and the other residents. During an interview on 7/25/2024 at 1:22 PM, Administrator (ADM) stated the facility should have looked into the staffing on 7/12/2024 at 3 PM to 11 PM shift and suspended CNA 1 until further investigation. A review of the facility's Policy and Procedure titled, Abuse, Neglect, Exploitation or Misappropriation Reporting and Investigating, revised 4/2021, indicated all allegations are thoroughly investigated. Policy also indicated any employee who has been accused of resident abuse is placed on leave with no resident contact until the investigation is complete. 055480 Page 2 of 2