Health inspection·January 24, 2023

The following reflects the finding of the California Department of Public Health during the investigation of: Entity Reported Incident (ERI) # CA00770723 and Complaint # CA00770982. Abbreviated Survey: Event ID: M16611 Representing the Department: HFEN # 43674 State Citation B was written Regulation: F-Tag 600 CFR § 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. (a) The facility must - (1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion; On 1/27/2022 at 11:35 A.M., an unannounced visit was conducted at the facility to investigate an entity reported incident and a complaint investigation regarding a resident to resident allegation of sexual abuse. Resident 1 was readmitted to the facility on 1/9/2022 with diagnoses that 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), and encephalopathy (an altered mental state). On 1/26/2022 around 12 A.M., Resident 2 was found by staff in Resident 1's room laying in bed with Resident 1. Resident 1's gown was above her hips and her intact brief was exposed. In addition, staff reported when Resident 2 was found laying in bed with Resident 1, Resident 2 stated he was bored and was "having fun with (Resident 1's last name)." The lack of identification, assessment, development and planning for Resident 2's admission did not ensure staff were ensuring the safety of all residents and had the potential for Residents to not be free from sexual abuse from Resident 2. The facility failed to ensure that Resident 1 was protected from the potential sexual abuse when: 1. Resident 2 who had a history of sexual violations, was listed on a registry (agency that tracked and monitored prisoners previously incarcerated as sex offenders) and was currently on parole, was not accurately assessed for safety and monitoring while around other Residents at the facility prior to accepting Resident 2 as a new admission. 2. After accepting Resident 2 as a new admission, there was no documented evidence related to the following: Accurate admission and ongoing safety assessment, development of interdisciplinary and core staff communication for the planning, monitoring and evaluating of Resident 2's plan of care to ensure Resident 2 did not interfere with other residents' safety. As a result, Resident 2 was found by staff in Resident 1's room laying in bed with Resident 1. Resident 1's gown was above her hips and her intact brief was exposed. In addition, staff reported when Resident 2 was found laying in bed with Resident 1, Resident 2 stated he was bored and was "having fun with (Resident 1's last name)." The lack of identification, assessment, development and planning for Resident 2's admission did not ensure staff were ensuring the safety of all residents and had the potential for Residents to not be free from sexual abuse from Resident 2. Findings: A review of Resident 1's undated Facesheet indicated, Resident 1 was readmitted to the facility on 1/9/2022 with diagnoses that 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), encephalopathy (an altered mental state), age related physical debility, and displaced femur fracture (broken bone of the thigh). A review of Resident 1's Minimum Data Set (MDS - a clinical assessment tool) and Brief Interview for Mental Status (BIMS - test used for cognitive function) dated 6/21/2021 indicated Resident 1 scored "3" which indicated severe impairment. A review of Resident 2's undated Facesheet indicated that Resident 2 was admitted to the facility on 12/31/2021. A review of Resident 2's registry from the agency that tracks and monitors prisoners, previously incarcerated offenders, indicated Resident 2's "Risk Assessment Score: Tool Level of Service/Case Management Inventory (LS/CMI - Risk assessment instrument used in California to predict risk of violent re-offense by sex offenders) Year: 2021 score 30. LS/CMI Score Categories indicated "30+ = Very High". A record review of Resident 1's Change of Condition Note dated 1/26/2022 at 12:10 A.M., completed by Licensed Nurse (LN) 1 indicated, "At approximately 12 midnight, resident (Resident 1) was seen laying down in her bed with a male resident (Resident 2). Residents (Resident 1 and Resident 2) were separated immediately. With Resident's (Resident 1) current level of consciousness, Pt (Resident 1) not oriented to current situation, to name, place or time, LN (Licensed Nurse - LN 1) and staff (Certified Nursing Aid - CNA 1) were unable to get accurate statement of the incident. LN (LN 1) and CNA (CNA 1) performed a head-to-toe assessment, no injury of skin alteration noted at this time. Peri-area appears normal and without signs of trauma. Pt (Resident 1) appears to not be in pain or discomfort. Pt (Resident 1) appears content and calm without signs of emotional distress. Notified MD (Doctor of Medicine) and RP (Responsible Party)." A record review of Resident 1's Change of Condition Note dated 1/26/2022 at 12:15 A.M., completed by LN 1 indicated, "Addendum: At the time of the incident, Pt's (Resident 1) clothes and diaper were on and intact. No signs of Pt (Resident 2) removing clothing. Head to toe skin assessment performed, no skin alterations or bodily fluids found. No foreign objects found. Pt's diaper was dry, clean, and intact. Pt's (Resident 1) psychological status at the time of incident was normal, no s/s [signs or symptoms] of emotional distress, Pt (Resident 1) was content and calm. No crying, whimpering, or moaning noted. Reported to Dr. (Name) and received order to report incident to management and to the police. Also ordered to send Pt out to (Name of Hospital) ER [Emergency Department] for further eval and tx [Evaluation and Treatment] for possible sexual abuse if the Pt's sister (Name of Sister) is agreeable d/t [related to] Pt being under hospice care [comfort care during terminal illness]." A record review of Resident 2's Change of Condition Note dated 1/26/2022 at 12:10 A.M., completed by LN 1 indicated, "At approximately 12 midnight, resident (Resident 2) was walking around the hallways of station (station number) , not long after staff (CNA 1) went to check where he (Resident 2) was at and he (Resident 2) was found in room (Resident 1's room number) laying down next to the female patient (Resident 1) in room (Resident 1's room number). Resident (Resident 2) was asked to leave the room immediately by staff (CNA 1) member. Pt (Resident 2) obliged and left the room right away. Resident (Resident 2) was very apologetic when LN (LN 1) asked what he (Resident 2) was doing in that room. Resident (Resident 2) stated ' I did not know that I wasn't allowed in there.' Residet [sic] (Resident 2) was informed that per company policy males and females cannot be in the same room. Pt (Resident 2) replied ' nobody told me that when I first got here.' Pt (Resident 2) denied performing inappropriate acts with the female resident (Resident 1) and claimed all he (Resident 2) did was lay down next to her (Resident 1) on the right side of bed. Notified MD and RP. Pt will be put on 72 hour visual checks." On 2/9/2022 at 8:48 A.M., a telephone interview was conducted with the Responsible Party (RP). The RP stated that Resident 1 mumbled off when communicating but had clear outburst at times. The RP stated that during her hospital visit with Resident 1 on 1/26/2022 at 3 P.M., Resident 1 had a clear outburst and stated "The guy from other house last night put his hand down there" - pointing at her groin area. The RP stated Resident 1 was restless and stated "Where is he? I am scared. He kissed me. He touched me. He pushed me." On 2/10/2022 at 7:30 A.M., a telephone interview was conducted with LN 1. LN 1 stated that around 12 A.M. of 1/26/2022, CNA 1 informed him that Resident 2 was found in Resident 1's room and was lying in bed with Resident 1. LN 1 stated that he conducted a full body assessment of Resident 1 with CNA 1. LN 1 stated Resident 1 was non-verbal and just mumbled, the diaper was intact, there were no injuries or marks noted during the skin assessment. On 2/11/2022 at 7:26 A.M., a telephone interview was conducted with Certified Nursing Assistant (CNA) 1. CNA 1 stated around 12 AM of 1/26/2022 Resident 2 was observed in the hallway. CNA 1 stated that after 5 minutes, Resident 2 was found lying in bed next to Resident 1. CNA 1 stated Resident 2 was "kind of smiling and embarrassed" that I found him lying in the bed next to Resident 1. CNA 1 stated Resident 1 was in bed laying on her back while Resident 2 was side lying facing Resident 1. CNA 1 stated Resident 1 was wearing her gown and the lower end of the gown was over the hips area. CNA 1 stated Resident 1's diaper was visible, and that the diaper was fastened. CNA 1 stated that Resident 2 apologized, made ' excuses", and told her "Me and her were adults", we are doing "adult things" by an "adult to adult", he was a man, was bored, and was "having fun with (Resident 1's last name)." On 3/30/2022 at 3:35 P.M., an observation and interview were conducted with Resident 1. Resident 1 was observed seated on the wheelchair in the dining area and was wheeled by a staff to her room. Resident 1 had no recall of the event during the interview. Additionally, the Social Services Director (SSD)was interviewed on 3/30/2022 at 4:40 P.M., and during the interview, the SSD did not have supporting documentation that Resident 1 was interviewed and did not recall the alleged event of Resident 2 lying in her bed. A review of Resident 2's Admission Referral, dated 12/29/2021 indicated Resident 2 was previously incarcerated and was on parole. A review of Resident 2's facility undated Face sheet entered by admission staff indicated Resident 2 was previously incarcerated and was on parole. A review of Resident 2's Skin Wound Note dated 1/1/2022 at 7:27 P.M., indicated "Skin assessment completed ... Left ankle bracelet[monitoring device for Resident 2 as part of his parole] noted ..." On 2/9/2022 at 11:26 A.M., an interview was conducted with the Administrator (ADM) 1. The ADM 1 stated that he was aware that Resident 2 was a parolee but was not aware of Resident 2's criminal history. The ADM stated that the facility did not have a procedure on the requirements and process of a parolee. The ADM stated that he had a conversation with a Parole Officer, the Parole officer stated that they were just checking on Resident 2, and that Resident 2 did nothing and was not in any trouble. On 2/9/2022 at 12:40 P.M., an interview was conducted with LN 3. LN 3 stated he was informed that Resident 2 had an ankle brace monitor and had a parole officer that came to the facility to check on Resident 2. On 2/18/2022 at 12:29 P.M., an interview was conducted with the Director of Staff Development (DSD). The DSD admitted that she was the admission nurse of Resident 2. The DSD stated it was not communicated to her during the hand off from the General Acute Care Hospital (GACH) that Resident 2 had an ankle bracelet and was followed up by a parole officer. On 4/20/2022 at 3:44 P.M., an interview was conducted with The Director of Nursing (DON) 2 and Corporate Acting Director of Nursing (CADN). During the interview, the DON indicated the DSD did Resident 2's admission paperwork from home via teleworking and this was not in accordance with the facility's admission process. Furthermore, the DON indicated the facility's expectation was for admissions to be conducted in person to prevent inaccurate assessments. On 2/9/2022 at 1:57 P.M., an interview and record review were conducted with the Director of Marketing and Admissions (DMA). The DMA stated that the process of admission was that the information provided by the transferring facility was compared to the facility's admission criteria. The DMA stated that if he was aware of Resident 2's criminal history the admission team would not have accepted Resident 2, and Resident 2's criminal history would be investigated prior to admission. On 2/9/2022 at 2:35 P.M., an interview was conducted with the Administrator (ADM) 1. The ADM 1 stated that the facility should have been aware of the criminal history of Resident 2. The ADM stated that indicators such as Resident 2's Parole Officer visiting the facility and the ankle bracelet worn by Resident 2, should have triggered further investigation of Resident 2's criminal history. On 2/9/2022 at 3:15 P.M., an interview was conducted with the ADM 1. The ADM 1 stated that he was not aware of any investigation by the Social Services Director (SSD) about Resident 2 being a parolee and Resident 2's criminal records. The Administrator stated it would be good to know the legal history of the resident as this could help the Interdisciplinary Team (IDT- a team of different types of staff that work together to share expertise, knowledge, and skills to impact on patient care) determine additional safeguards for the residents. On 2/18/2022 at 12:02 P.M., a joint interview and record review were conducted with Director of Staff Development (DSD). The DSD stated there was no investigation or inquiries documented in Resident 2's Progress Notes except the note on 1/3/2022 at 7:44 P.M. completed by Social Services Director (SSD) that indicated "Resident has a Parole Officer that per resident will be checking in on him ..." The DSD stated the progress note dated on 1/1/2022 at 7:27 P.M., completed by LN 2 indicated " ...Left ankle bracelet noted ..." The DSD stated there were no other documentations in Resident 2's medical record about resident's background, social history related to Resident 2 being a parolee. On 4/20/2022 at 3:30 P.M., a joint record review and interview with Director of Nursing (DON) 2 was conducted. The DON 2 stated Resident 2's Admission Notes was dated 12/31/2021 at 21:37 P.M. and completed by Director of Staff Development and indicated "admitted ...at approximately 2039 via (name of transport company) ..." Resident 2's LN-Initial Admission Record was completed by DSD and had "Effective Date: 12/31/2021 at 20:39" In addition on 4/21/2022 an interview and record review were conducted with DON 2 and Administrator (ADM) 2. The DON 2 stated DSD's timecard indicated she worked on 12/30/2021 from 6:30 PM until 12/31/2021 at 7:00 AM and on 12/31/2021 from 10 AM to 9 PM. In addition, on 4/21/2021 at 5 P.M., the DON 2 and the ADM stated based on timecard, they would not know which hours were worked from home and hours worked in the facility. Per DON 2, during the investigation and inquiry about the multiple hours, the DSD stated "I do admission assessment from home". A review of Admission Note by DSD indicated. "Effective Date: 12/31/2021 21:37:00" The DON 2 stated, effective date was the date and time the content of the document happened. "Created date: 1/2/2022 16:38:53" refers to date and time the note was created or completed. In addition, a review of LN-Initial Admission Record indicated "Effective Date: 12/31/2021 20:39 ... Signed by (DSD) Licensed Vocational Nurse - Hourly [e-SIGNED] ... Signed Date 1/26/2022". The DON 2 stated the signed date and time meant the time it was signed and completed. The DON 2 reviewed the file of Resident 2 and stated the signed date of 1/26/2022 was the day of discharge of the resident from the facility. On 2/18/2022 at 1:18 P.M., an interview was conducted with the Activities Director (AD). The AD stated on 1/1/2022, she noticed the left ankle bracelet during Resident 2's activity assessment. The AD stated that she informed the SSD, the Director of Nursing (DON) and the staff that attended the daily stand-up meeting. On 2/18/2022 at 2:51 P.M., an interview was conducted with the Corporate Acting Director of N