Health inspection·July 25, 2025

The following reflects the findings of the California Department of Public Health during an observation of facility reported incident CA00952412. Event ID: 3PRD11 Representing the Department, HFEN 46552 Citation B was written. REGULATORY VIOLATIONS: Code of Federal Regulations, Title 42 F600 §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. On 3/20/2025 an unannounced visit was conducted at the facility to investigate an entity reported incident regarding resident-to-resident abuse. The facility failed to ensure one of three sampled residents (Resident 1) was free from sexual abuse (sexual act that is committed or attempted by another person who is incapable of appraising the nature of the act or unable to give consent) when certified nursing assistant E (CNA E) did not separate female Resident 1 from male Resident 2. As a result of above failure, Resident 1's naked waist down body and Resident 1's private area was exposed to Resident 2. Review of Resident 1's undated face sheet (FS: a document that gives a resident's information at a quick glance) indicated Resident 1 was admitted to facility on 6/13/2023. Review of Resident 1's FS indicated diagnoses included schizoaffective disorder (a chronic mental illness that causes a person to experience dramatic changes in their thoughts, moods and behaviors), bipolar disorder (a mental illness that causes clear shifts in a person's mood, energy, activity levels, and concentration),anxiety (persistent, excessive fear or worry for day to day situations), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest in daily living), dementia (loss of thinking, memory, language and reasoning skills) and hospice care (a specialized care designed to provide comfort and support to individuals with terminal illness). Review of Resident 1's minimum data set (MDS: Resident's clinical and functional assessment tool) assessment dated 12/7/2024 indicated Resident 1's brief interview for mental status (BIMS) score of 8 of 15 which means 8-12 with moderately impaired cognition. Review of Resident 1's medical doctor (MD)'s progress notes dated 3/20/2025 indicated, "orientation to person only, not to place or time." Review of Resident 1's document for change in condition (CIC: a document used to document and report a change in a resident's physical and mental health) evaluation dated 3/18/2025 indicated, "Resident 1 was found in Unit of Resident 2[DF1]'s bed laying down with no pants or brief on. The male resident was standing next to her." Review of Resident 2's FS indicated Resident 2 was admitted to facility on 1/30/2025 with diagnoses of dementia and anxiety. Review of Resident 2's MDS assessment dated 2/5/2025 indicated, Resident 2's BIMS score of 12 of 15, which means 8-12 with moderately impaired cognition Review of Resident 2's document for CIC evaluation dated 3/18/2025 indicated, "Resident 2 was seen with Resident 1 on his bed. Resident 1[DF2] had no clothes waist down and laying down with Resident 2's[DF3] bed while Resident 2 was standing up fully clothed, but belt buckle undone." During an interview with LVN D on 3/20/2025 at 3:35 p.m., LVN D (licensed vocational nurse D) stated CNA E came to LVN D, (LVN D that time was in another unit adjacent to Resident 2's unit) CNA E reported saying that Resident 1 and 2 were in Resident 2's room when CNA E tried to separate both, Resident 2 became aggressive and threatened to hit CNA E on 3/18/2025 around 4:30 p.m. LVN D stated CNA E did not separate both residents, left the Resident 2's room to report to LVN D. Few minutes later when LVN D walked into Resident 2's room, LVN D noted privacy curtain was around Resident 2's bed, Resident 1 was laying in Resident 2's bed with no clothes waist down, naked. LVN D also stated Resident 2 was standing at the foot of the bed with full clothes on, belt buckle undone. LVN D further stated Resident 1's waist down naked body and Resident 1's private area was exposed to Resident 2. LVN D confirmed there were no staff in the room when he arrived at Resident 2's room. LVN D also stated he was able to get help from another staff, separated both residents and dressed Resident 1. LVN D also stated CNA E should not have left both male and female residents together in room without staff's presence before leaving the room report to him. LVN D further stated CNA E should have stayed with both residents or separated both residents to prevent sexual abuse altercation (a dispute or conflict involving sexual activity or interactions including inappropriate looking) between Resident 1 and Resident 2. During an interview with CNA E on 3/20/2025 at 3:55 p.m., with the presence of facility's director of staff development (DSD), CNA E stated she noticed Resident 1 sitting on Resident 2's bed, fully clothed. When CNA E tried to separate both residents, Resident 2 became aggressive, threatened to hit CNA E with belt and asked CNA E to leave the room. CNA E got scared, called for help, no staff came. CNA E left the room and walked to another unit to report to charge nurse (charge nurse was in other unit that time). CNA E also stated she did not separate both residents before she left to report to the charge nurse. CNA E also stated she should have waited for help to come or separated both residents before she left Resident 2's room to prevent sexual abuse altercation between Residents 1 and 2. During an interview with DSD on 3/20/2025 at 4:14 p.m., DSD stated CNA E should have not have left Resident 1 and 2 in a room for Resident 1's safety and prevent sexual altercation. DSD also stated this sexual abuse altercation could have been prevented if CNA E did not leave Resident 2's room or separated Resident 1 from Resident 2. During an interview with facility's assistant director of nursing (ADON) on 3/20/2025 at 4:20 p.m., ADON stated CNA E should not have left both male and female residents in a room together alone to prevent sexual altercation and to maintain safety of the female resident. During an interview with facility's director of nursing (DON) on 4/18/2025 at 1:32 p.m., nursing staff should have separated both residents to prevent and make sure residents were free from sexual abuse altercations. Review of facility's policy and procedure (P&P) titled, "Abuse Prevention Program," revised December 2016, the P&P indicated, "Our Residents have the right to be free from abuse." The facility failed to ensure one of three sampled residents (Resident 1) was free from sexual abuse (sexual act that is committed or attempted by another person who is incapable of appraising the nature of the act or unable to give consent) when certified nursing assistant E (CNA E) did not separate female Resident 1 from male Resident 2. As a result of above failure, Resident 1's naked waist down body and Resident 1's private area was exposed to Resident 2. This violation had a direct or immediate relationship to the health, safety, or security of patients or residents.